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Background Context: Surgical management of complex spinal reconstructions remains a clinical challenge, as pseudoarthrosis with subsequent rod breakage can occur. Increased rod density in the form of "satellite" or "outrigger" rods have been described; however, rod-fracture above or below satellite rods persist and can result in dissociation of the construct, loss of correction, and recurrence of deformity. The use of four distinct and mechanically independent rods (dual construct) reduces this concern. Since the original case description in 2006, there have been no other studies that use the dual construct for the surgical management of complex spinal reconstructions.Purpose: The purpose of this study is to review the long-term experience and surgical technique using the dual construct, and to present our complications, rod fracture rates, and outcomes for the surgical management of complex spinal reconstructions.Study Design: This study used a surgical technique with case series outcomes.Patient Sample: Patients were from a single-institute who underwent dual construct between 2010 and 2014 and who were available for 2-year follow-up.Outcome Measures: Radiographic and functional outcomes, complications, rod fracture rates, and revision surgery rates were the outcome measures.Methods: A retrospective review was conducted from a single institution between 2010 and 2014, with a subsequent 2-year follow-up period. Extensive review of patients' medical record, radiographs, and advanced imaging where available was performed. Medical record was evaluated for patient demographics, surgical procedure, and complications. Radiographic measurements included presence or absence of implant failure and proximal junctional kyphosis or distal junctional kyphosis.Results: A total of 36 patients underwent surgical reconstruction. The average estimated blood loss was 1,856 cc (range, 400-4,000 cc). The average length of stay was 7.3 days (range, 4-22 days). Clinical follow-up reported 21 patients (58.3%) with no or minimal pain. There were six deaths during the follow-up unrelated to the index procedure. Radiographic follow-up revealed three patients (8.3%) with rod fracture; one patient with one rod fracture, and two patients with two rod fractures. No patient had three or all four rod fractures. There were no screw fractures. None of the patients with rod fractures required revision surgery.Conclusions: The biggest advantage of the dual construct is that rod breakage, although uncommon, is typically minimal, or asymptomatic, and more importantly does not result in loss of alignment, and therefore has not required revision surgery. The dual construct approach is a safe alternative to traditional two-rod constructs, with encouraging outcomes at follow-up. [ABSTRACT FROM AUTHOR]

Background Context: Cost-utility analysis, a special case of cost-effectiveness analysis, estimates the ratio between the cost of an intervention to the benefit it produces in number of quality-adjusted life years. Cervical deformity correction has not been evaluated in terms of cost-utility and in the context of value-based health care. Our objective, therefore, was to determine the cost-utility ratio of cervical deformity correction.Study Design: This is a retrospective review of a prospective, multicenter cervical deformity database. Patients with 1-year follow-up after surgical correction for cervical deformity were included. Cervical deformity was defined as the presence of at least one of the following: kyphosis (C2-C7 Cobb angle >10°), cervical scoliosis (coronal Cobb angle >10°), positive cervical sagittal malalignment (C2-C7 sagittal vertical axis >4 cm or T1-C6 >10°), or horizontal gaze impairment (chin-brow vertical angle >25°). Quality-adjusted life years were calculated by both EuroQol 5D (EQ5D) quality of life and Neck Disability Index (NDI) mapped to short form six dimensions (SF6D) index. Costs were assigned using Medicare 1-year average reimbursement for: 9+ level posterior fusions (PF), 4-8 level PF, 4-8 level PF with anterior fusion (AF), 2-3 level PF with AF, 4-8 level AF, and 4-8 level posterior refusion. Reoperations and deaths were added to cost and subtracted from utility, respectively. Quality-adjusted life year per dollar spent was calculated using standardized methodology at 1-year time point and subsequent time points relying on maintenance of 1-year utility.Results: Eighty-four patients (average age: 61.2 years, 60% female, body mass index [BMI]: 30.1) were analyzed after cervical deformity correction (average levels fused: 7.2, osteotomy used: 50%). Costs associated with index procedures were 9+ level PF ($76,617), 4-8 level PF ($40,596), 4-8 level PF with AF ($67,098), 4-8 level AF ($31,392), and 4-8 level posterior refusion ($35,371). Average 1-year reimbursement of surgery was $55,097 at 1 year with eight revisions and three deaths accounted for. Cost per quality-adjusted life year (QALY) gained to 1-year follow-up was $646,958 by EQ5D and $477,316 by NDI SF6D. If 1-year benefit is sustained, upper threshold of cost-effectiveness is reached 3-4.5 years after intervention.Conclusions: Medicare 1-year average reimbursement compared with 1-year QALYdescribed $646,958 by EQ5D and $477,316 by NDI SF6D. Cervical deformity surgeries reach accepted cost-effectiveness thresholds when benefit is sustained 3-4.5 years. Longer follow-up is needed for a more definitive cost-analysis, but these data are an important first step in justifying cost-utility ratio for cervical deformity correction. [ABSTRACT FROM AUTHOR]

Background Context: With advances in the understanding of adult spinal deformity (ASD), more complex osteotomy and fusion techniques are being implemented with increasing frequency. Patients undergoing ASD corrections infrequently require extended acute care, longer inpatient stays, and are discharged to supervised care. Given the necessity of value-based health care, identification of clinical indicators of adverse discharge disposition in ASD surgeries is paramount.Purpose: Using the nationwide and surgeon-created databases, the present study aimed to identify predictors of adverse discharge disposition after ASD surgeries and view the corresponding differences in charges.Study Design/setting: This is a retrospective analysis of patients on the National Surgical Quality Improvement Program (NSQIP) database and of cost data from Medicare PearlDiver Database.Patient Sample: Patients undergoing thoracolumbar surgery for correction of ASD were included in the study.Outcome Measures: Primary analysis was performed to compare patients discharged to home with patients who either expired or were discharged to locations other than home. Secondary analysis was performed to determine the cost differences across discharge groups.Methods: Patients on NSQIP undergoing thoracolumbar ASD-corrective surgery with a primary diagnosis of scoliosis (ICD-9 code 737.x) and over the age of 18 were isolated. Predictors (demographic, clinical, and complications) of not-home (NH; rehab or skilled nursing facility) discharge were analyzed using binary logistic regression controlling for levels fused, decompressions, osteotomies, and revisions. Average 30- and 90-day costs of care were reported in home, rehab, and skilled nursing facility discharge groups in patients undergoing 8+ level thoracolumbar fusion.Results: A total of 1,978 patients undergoing lumbar ASD-corrective surgery were included for analysis (average age: 59.3 years, sex: 64% female). Average length of stay was 6.58 days. On multivariate regression analysis, age over 60 years (odds ratio [OR]: 0.28, confidence interval [CI]: 0.22-0.34) and female sex (p=.003) were independent predictors of adverse discharge status. Partially dependent preoperational functional status, defined as reliance on another person to complete some activities of daily living, increased likelihood of adverse discharge disposition (OR: 0.57, CI: 0.35-0.90). Despite controlling for all clinical variables except for the ones specific to each analysis, Smith-Petersen osteotomy (OR: 0.51, CI: 0.40-0.64), interbody device placement (OR: 0.80, CI: 0.64-0.98), and fixation to the iliac (OR: 0.54, CI: 0.41-0.70) increased the likelihood of adverse discharge. Complications most associated with adverse discharge were urinary tract infections (OR: 0.34, CI: 0.21-0.57) and blood transfusions (OR: 0.42, CI: 0.34-0.52). Relative to home discharge, 30-day costs of care were +$21,061 more expensive in rehab discharges, but not different in skilled nursing facility discharges (+$5,791, p=.177). The 90-day costs of care were $23,815 in rehab discharges (p<.001), but again not different from skilled nursing facility discharges (+$6,091, p=.212).Conclusions: Discharge destination to rehabilitation has a significant impact on the cost of thoracolumbar ASD surgeries. Patient selection can predict patients at higher risk of discharges to rehab or skilled nursing facility. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT The incidence of lumbar fusion surgery for the treatment of degenerative conditions is increasing rapidly in the elderly population. In appropriately selected patients with symptomatic lumbar degenerative disease, lumbar interbody fusion has been shown to provide substantial improvement, regardless of the specific technique chosen. The anterior approach affords a number of benefits, but has been associated with a 2-3times higher incidence of postoperative ileus compared to the transforaminal or posterior approaches. PURPOSE The purpose of this study was to identify the independent risk factors, additional length of stay, and additional cost associated with postoperative ileus following anterior lumbar interbody fusion in the elderly. STUDY DESIGN/SETTING Retrospective analysis of Medicare insurance database. PATIENT SAMPLE Elderly patients with Medicare insurance treated between 2005 and 2014. OUTCOME MEASURES The primary outcome measure studied was the incidence of postoperative ileus. Secondary outcome measures included average hospitalization cost and length of stay. METHODS Records of patients with Medicare insurance were retrospectively reviewed to identify patients 65years of age and older undergoing 1 or 2 level primary elective anterior lumbar interbody fusion from 2005 to 2014. Independent risk factors, additional length of stay and additional cost associated with postoperative ileus were evaluated with multivariate analysis. RESULTS A total of 13,139 patients were identified. Of the identified patients, 642 experienced postoperative ileus within 3days of surgery. Multivariate analysis identified fluid and electrolyte imbalance within 3days of surgery (odds ratio=4.03, P<.001) and male sex (odds ratio=1.72, P<.001) as independent risk factors for ileus. Multivariate analysis also associated postoperative ileus with additional length of stay of 2.83 days±0.11days (P <.001) and additional cost of $2,349±$419 (P<.001). CONCLUSIONS Patients with perioperative fluid and electrolyte imbalances were 4times as likely to experience postoperative ileus. Fluid balance and electrolytes should be carefully monitored during the perioperative period in patients undergoing anterior lumbar interbody fusion as a potential means to reduce the incidence of postoperative ileus and the additional length of stay and cost burden associated with this complication. [ABSTRACT FROM AUTHOR]